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PEMERINTAH KABUPATEN GUNUNG MAS

PUSKESMAS TUMBANG TALAKEN


KECAMATAN MANUHING
Jl.Negara No.46 Tumbang Talaken Kecamatan Manuhing Kode Pos 74562

PERMINTAAN RAWAT INAP


Nomor RM :

Dikirim oleh : IGD/Poliklinik............................................................ .

Ruangan Tujuan : Ruang.........................................................................

Tanggal Permintaan Opname :.....................................................................................

Pasien

Nama Pasien : ................

Tgl.Lahir / Umur : .....................................................................................

Alamat : ...................................................................................

Nomor BPJS (NKA) : ...................................................................................

Diagnosa :....................................................................................

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Dokter yang mengirim,

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Menerangkan bahwa pasien tersebut diatas dirawat di Puskesmas Tumbang Talaken

Sejak Tanggal :.......................................................................................................................

Bagian/Ruangan : Ruangan ........................................................................................................

Dokter yang merawat,

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